Daryl Corr explains how quality Rx care is maximizing workers’ compensation prescription drug savings and ensuring the highest level of care for injured workers.
While the overall number of workers' compensation claims has decreased over the past few years, insurance industry studies show medical treatment costs are continuing to grow at an alarming rate with prescription drugs being one of the major contributors. The impact, however, isn't solely driven by the price of the drugs, but instead, it has been due to increased utilization - more drugs are being prescribed to more claimants, for longer durations. In many cases there are more appropriate and cost effective treatment alternatives - but better managing this process requires more focus and expertise than what is provided in most Pharmacy Benefit Management (PBM) programs, especially when comparing workers' compensation benefits to group health.
One of the major challenges workers' compensation insurance programs encounter with controlling medication costs is ensuring injured workers are being prescribed the most effective and appropriate drugs to treat an injury or work related illness. Since the complexity of injuries and patient medication tolerances can vary so significantly, combined with the challenge of wide scale use of pain medications, treatments can't be a one size fits all approach. Therefore, it's critical to incorporate more clinically focused strategies to ensure prescription drug treatments are being managed appropriately.
At the most basic level, a clinical services program helps insurance payers design and maintain a pharmacy program's medication plan, or formulary, around the specific medications or classes used to treat workers' compensation injuries. These rules can help determine whether a drug requires a prior authorization before dispensing. However, on a more targeted level, a successful clinical program can have a big impact when focused on the most complex cases. These complex cases may represent a small percentage of an insurance payer's injured worker patient population, but they have a tendency to drive most of the cost. Typically, less than 10% of a payer's claimants receiving prescription drugs are driving more than 70% of their overall drug treatment costs. So, focusing more attention on this narrow group of claims maximizes the opportunity to significantly reduce drug spend. However, it requires a lot more expertise and commitment from the PBM to achieve the best savings results. You need a highly skilled and knowledgeable staff of PharmD clinicians focused on examining individual cases, analyzing drug therapies and identifying alternate treatment options - subsequently interacting with physicians and claims professionals to provide education about more appropriate alternatives when they are available. This approach focuses on the higher dollar claims in order to maximize the potential savings impact.
The most successful clinical tools are highly integrated into a PBM's overall program. The critical pharmacy program functions necessary to make this happen are powerful technology and proactive communication. The technology quickly and proactively identifies problematic prescription trends using systems edits and evidence based medical guidelines, while proactive communication facilitates interactions between the PBM, the prescribing physician and the insurer's claims professional. A PBM's team of PharmD professionals needs to actively interact with physicians to provide education and insight into the specifics about the prescribed drugs and the injuries they are treating. Frequently a physician may not even be aware of all medications being prescribed to an injured worker if they are being treated by multiple physicians. Clinical education and outreach is imperative and must occur quickly in order to be most effective.
There is also a need to proactively monitor the pharmaceutical industry to identify new drugs that are entering the market, which may impact a pharmacy program. The key is to help clients make the right decisions by factoring both treatment effectiveness and cost. It isn't solely driven by the price of one pill. It's about applying the right treatment to achieve the optimal outcome, which typically equates to lower costs over the life of the claim.
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